Inside: Sundowning program | Pressure sores | Seniors in transition | Self-care
October 2017 Edition
Virtual reality for dementia care Page 14
Innovation to Impact Visit cabhi.com to learn how you can accelerate your aging and brain health innovation.
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AFTER AGE 65, THE LIKELIHOOD OF NEEDING AN MRI DOUBLES. THIS AGE GROUP IS ALSO MORE LIKELY TO NEED A PACEMAKER.1 PATIENTS WITH PACEMAKERS HAVE A 50-75% LIKELIHOOD OF NEEDING AN MRI OVER THE LIFETIME OF THEIR DEVICE.1 1. 2.
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Cover story: Virtual reality
Antipsychotic use in residential care
4 8 10 16 18 23 26 29 31
Medical assistance in dying
Music works in dementia care
Editorâ€™s Note Seniors in transition Navigating the health and social system Caregiver SOS Virtual reality calms Alzheimerâ€™s patients Public inquiry leads to better care Improving oral health Skin and wound detective Ambiguous loss and grief
Early onset dementia
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success ccording to The Alzheimer Society of Canada there are over half a million (564,000) Canadians living with dementia. In 15 years , that number is expected to nearly double to 937,000. Many of us have been or will be touched by this disease. Alzheimer’s, the most common cause of dementia (but not the only cause) can be a very challenging disease to manage, whether in a long-term care facility or a home care setting. Often times, people suffering from Alzheimer’s or dementia can exhibit disruptive responsive behaviour, usually as a result of being unable to communicate a specific need to their caregiver. This month’s cover story, Virtual reality in dementia care explores how providing a digital world can soothe patients, and assist caregivers in managing disruptive behaviour. Researchers are currently performing pilots on the use of virtual reality in both the long-term and home care settings. This month’s issue also features an article on sun-downing, and how a night-owls program at one long-term care facility has decreased responsive behaviours, lowered fall rates and increased engagement with residents. Something as simple as providing programming and company to residents who are up at night and sleep during the day can reap huge benefits for both the residents and healthcare professionals who care for them. You will also find useful information on wound care, pressure sores, Medical Assistance In Dying, how music can help in dementia care and guidelines on reducing antipsychotic medication use in residen-
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UPCOMING DEADLINES NOVEMBER 2017 ISSUE EDITORIAL: October 11 ADVERTISING: Booking and Material – October 17 tial care. We have also included a monthly column entitled self-care. This column will provide insight and information on how to ensure you are caring for yourself (physically, mentally and spiritually). This month’s column offers tips on how to care for your feet after long shifts on them. The stories you will read in this magazine often feature a new and innovative technology, but they will also highlight simple solutions that are developed by those working on the front-lines, either as a professional or informal family caregiver. Who better to provide solutions to the challenges in caregiving than the people who live it every single day? If you have a caregiving success to share, please email me at firstname.lastname@example.org LC
Kristie Jones Editor, Home and Long Term Care News
4 Home and LongTerm Care News OCTOBER 2017
DECEMBER 2017 ISSUE EDITORIAL: November 10 ADVERTISING: Booking and Material – November 21 Home and Long Term Care News is published for consumers who are supporting and/or involved in home care or long term care. It is available free of charge from distribution racks in hospitals across Ontario. The statements, opinions and viewpoints made or expressed by the writers do not necessarily represent the opinions and views of Home and Long Term Care News, or the publishers. Home and Long Term Care News and Members of the Advisory Board assume no responsibility or liability for claims, statements, opinions or views, written or reported by its contributing writers, including product or service information that is advertised. Changes of address, notices, subscription orders and undeliverable address notifications, and inquiries can be sent to: email@example.com Subscription rates in Canada for single copies is $35.00 per year. Canadian Publications mail sales product agreement number 40065412. From the publishers off Hospital News, reporting on health care news and best practices for over 30 years.
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Sundowning program helps manage responsive behaviours By Drew Tapley bout 80 per cent of residents at Camilla Care Community in Mississauga, Ontario, display some form of dementia-related responsive behavior. A lot of the antipsychotic medication they are prescribed has side effects that include falling asleep and drowsiness; and sometimes these residents switch night and day – known as ‘sundowning’ – and are up at night, often restless. Mariam Mehreban is the director of resident programs at Camilla, part of Sienna Senior Living, and came up with the idea for the Night Owl program in January 2015 when she
began to notice a significant change in the residents being admitted. “As the needs of the resident population changes, the way we deliver programs has to change as well,” says Mariam. “Every responsive behaviour means there is a need that is not being met. Programs that worked a year ago may not work today, and even the lingo and language within care communities is changing.” Night Owl is offered five nights a week, from 11.30 p.m. to 7.30 a.m., and consists of one full-time recreation team member. The goal is to increase it to seven days.
The program provides therapeutic engagement, one-on-one or in small groups, and the response has been positive because, Mariam points out, it doesn’t conflict with meal service, baths and showers. It’s conducted in a very quiet lounge area during the night, which is utilized for meal service, family visits and programs during the day. These busy activities have been known to trigger a lot of responsive behaviours. Rose Bramwell is the recreation aide who has been running the program since January 2015. She says residents can be more engaged in programs that run at night.
“There is not all the congestion and commotion during the night. Programs are more effective, and have better results,” says Rose. “Residents don’t realize that they need rest and should to go to bed, and want human contact most of the time. I find that they want to be engaged and interact with me or each other, and talk about their lives and interests. Music tends to be a big topic.” Groups average anywhere from three to eight residents, and tend to vary each night, and each hour. The same residents don’t necessarily turn up night after night, or even two consecutive nights in a row. Rose says that residents are able to develop friendships through the program, and remember a face and an interaction even though they might not remember what they were talking about. “These were residents we weren’t able to reach before because if they were up at night they were sleeping during the day,” Rose says. “Their activity involvement and socialization has increased, and we’ve noticed a decrease in their responsive behaviours.” Night Owl offers residents different activities, such as art therapy, doll therapy, and sensory stimulation like hand massage, listening to soft music, walking and engaging them in conversation. They might even bake bread, depending on the interests of the individual. And some might just be looking for food or drink.
Mariam Mehreban (left) and Rose Bramwell from the Night Owl program.
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Mariam and Rose with residents at Camilla Care Community.
Even residents who don’t have responsive behaviours but are awake at night take advantage of the program. Seniors generally tend to have more naps during the day, and are therefore not going to have a continuous six or seven hours of sleep at night. “I think we are the only home in Canada that offers this program for residents who experience sundowning or night owling,” says Mariam.
“On the nights when there is no Night Owl, we look at the Dementia Observation System and documentation on PPC, and notice increases in falls, responsive behaviours and restlessness.” But despite the program, some responsive behaviors still occur. “There are times when a resident is in pain or needs to be toileted and can’t express it, which is sometimes
one of the triggers,” says Rose, who explains how the program is continually evolving. Camilla’s resident and family engagement surveys show lots of positive feedback and support for Night Owl, which was initially focused solely on responsive behaviors. Now, about five per cent of residents who don’t engage during the day will come to the program and engage with a craft.
There might also be a wider application for the program in the local community where spouses are still the primary caregivers, and can easily get burnt out. “There are adult day programs, but nothing during the night to give that caregiver a break,” says Rose. “Perhaps switching some programs to night will allow people to attend and continue living out in the community.” LC
Drew Tapley is a Writer with Sienna Senior Living.
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Seniors in transition:
The right care in the right place for the right patient By Riley Denver
anada is in the middle of a demographic shift that will impact health system decisions for the foreseeable
future. For the first time, seniors outnumber children and over the next 20 years, growth in the older seniors’ population (age 75 and older) is expected
to accelerate and to double in size. Health systems are already experiencing significant pressure in all sectors as they respond to the needs of seniors — including a desire for independence and to remain in their homes as long as possible. Faced with this changing demographic landscape, Canada’s health
8 Home and LongTerm Care News OCTOBER 2017
system has been presented with an important question: How can we best meet the unique needs of this growing population?
SENIORS IN TRANSITION Seniors in Transition: Exploring Pathways Across the Care Continuum – a
report from the Canadian Institute for Health Information (CIHI) – is a multi-year study of more than 59,000 seniors in Canada. The focus of the report is to better understand how Canada’s seniors transition from living independently to receiving continuing care services, and what factors influence their transition into residential care. The study found that as many as one in five seniors admitted to residential care might have been able to remain at home with appropriate support. This finding underlines the need for additional community-based supports to help seniors maintain their independence as long as possible. Admitting seniors to residential care who may have been able to be supported in home care can have undesirable consequences. It can result in a longer stay in residential care, a negative impact on patient outcomes and potential displacement of higher-needs individuals. There are seniors who enter residential care with care needs that are similar to those of seniors who are typically supported in the community. Factors that influence whether someone enters residential care include: • The need for physical assistance • Cognitive impairment • Wandering behaviours • Living alone • Having a caregiver who is unable to continue providing care The findings also showed that seniors whose needs were assessed in hospital were over six times more likely to enter residential care than those assessed in the community. However, seniors assessed in hospital may have higher needs than those assessed in the community, explaining their higher priority for admission to residential care.
“What we regularly see now is the need to consider a patient’s pre-hospital functioning when developing care plans,” says Steve Atkinson, CIHI’s Manager, Analytics and Research Projects. “This helps hospital staff understand how patients function in their normal day-to-day lives and allows them to make treatment plans that enable patients to return to their normal living arrangements.” To help people better understand the populations served by home care and residential care in selected health regions, CIHI developed an interactive online tool that allows users to observe characteristics of seniors’ populations over time and across care settings, at the health region level.
WHAT’S NEXT? As the proportion of older seniors in Canada continues to climb, the num-
ber of people who will require care is expected to grow. Ensuring there is capacity to meet the pending demand of a growing population of seniors means transforming the way care is provided. Making sure that health services match the needs of the population, and that current beds and home health services are used appropriately, may allow health systems to maximize the efficient use of their resources. There are many innovative approaches being introduced across the country designed to meet client and caregiver needs in the home, often featuring improved integration across healthcare systems and leveraging new technologies. The challenge for health system decision-makers, care providers and planners going forward is exploring ways to expedite their implementation in order to address the future needs of the continuing care sector. LC
Riley Denver is the Communications Specialist at The Canadian Institute for Health Information (CIHI).
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Navigating the health and social system a challenging part of caregiving By Amélie Quesnel-Vallée and Miles Taylor t’s a fact: the Canadian population is aging. For the first time in history, Canadians 65 years and over outnumber those 14 years and under. To face this major demographic change head on, we need to adapt. In particular, to meet the preferences of the great majority of Canadians who want to age in the community, we will have to rethink how we support the caregivers that make this possible. But how do we provide better support to caregivers? In a recent journal article, my colleague and I argue we must begin by recognizing that the fragmentation of the health and social systems itself is generating a substantial amount of burden for caregivers. Yet this “structural burden” of caregiving often goes unrecognized by the system, not to mention caregivers themselves. Part of the reason is that research up until now has mainly defined caregiving burden in terms of the amount of time and stress it takes to physically provide care to another person – helping with daily tasks and personal hygiene for instance. But what about the time spent negotiating healthcare systems,
WE SHOULD INCREASINGLY ASK HOW MUCH TIME AND STRESS IS EXPENDED BY CAREGIVERS NEGOTIATING WITH MEDICAL AND SOCIAL CARE SYSTEMS, TRYING TO FIGURE OUT WHICH SERVICES ARE AVAILABLE AND WHEN. scheduling and getting to and from treatments, often in the middle of the day, figuring out which services will be covered and under which circumstances? That part of the caregiving burden isn’t well-articulated, measured or understood. And it certainly isn’t often appreciated. As academics in the fields of aging and health services research, we, ourselves, really only fully came to realize what this part of caregiving means to the caregiver when we began more actively providing care for our aging parents. We thought we knew what we were getting ourselves into. We anticipated that providing direct care would be challenging and we knew what help to seek and where. What we were not prepared for was how much time and stress we would spend trying to understand, negotiate and
manage medical and social care for our loved ones. What was particularly surprising was that we both encountered this problem via two very different health systems: one in Quebec and one in Florida. Of course, financial worries for health provision were much less prevalent in Quebec than in Florida, but they were not altogether absent, as the home and long-term care sector is very much privately financed in Quebec (and throughout the rest of Canada). Ultimately, we both struggled in remarkably similar ways with negotiating and managing discontinuous and fragmented care and services. And despite the difficulties we encountered, we recognized that our social position, in terms of education, income and even profession, gave us more social currency and health
care literacy than most – and likely helped us gain information and access services. This realization left us concerned for the potential that this structural burden has for exacerbating social inequalities among patients and caregivers. The market has already figured out this opportunity. Private case manager services exist in both countries to assist caregivers navigating the system. This indicates that there is a real need out there, and that shortcomings in the public sector are being fulfilled by the private sector, at the cost of equitable access.
Amélie Quesnel-Vallée is an expert advisor with EvidenceNetwork.ca, the Canada Research Chair on Policies and Health Inequalities and Director of the Observatory on Health and Social Services Reforms at McGill University. Miles Taylor is Associate Professor of Sociology and Faculty Associate at the Pepper Institute on Aging and Public Policy at Florida State University and a Fellow of the Gerontological Society of America. 10 Home and LongTerm Care News OCTOBER 2017
Governments need to start investing in care navigators to ensure equitable access to publicly funded services and supports
So what can be done? First, the “structural burden” of caregiving has to be included in health policy research and health reform. Right now, for example, most surveys on caregiving only question how much time caregivers take feeding or bathing their care recipient or providing other daily tasks such as taking out the trash. We should increasingly ask how much time and stress is expended by caregivers negotiating with medical and social care systems, trying to figure out which services are available and when. The answer might surprise many health policy analysts – but it won’t surprise caregivers.
With these numbers in hand, we could advocate for support from governments to fund public navigator services. These services already exist in certain areas of the system, such as in cancer and palliative care, but they are not widespread and readily available to individuals without such clear diagnoses and prognoses. In our experience, it would have made a world of difference to be able to rely on such support. It’s also important that everyone understand the time and stress involved in managing care and negotiating services is also caregiving. It can be a substantial burden that should be acknowledged and recognized. Because if we don’t care for the caregivers, who will? LC
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Supporting healthcare providers wanting to participate in
Medical Assistance in Dying By Dr. Paul Preston hen someone is suffering with a serious, incurable terminal illness – and looming ahead is further decline and symptoms, followed by death – palliative care provides relief. Now, following the Supreme Court of Canada’s recognition of Medical Assistance in Dying (MAID) as a constitutional right, people who find
MEDICAL ASSISTANCE IN DYING IS A LEGAL OPTION IN CANADA themselves in this situation have an additional option to manage their suffering. MAID allows doctors and nurse practitioners to help patients with terminal illnesses to end their lives after
12 Home and LongTerm Care News OCTOBER 2017
a thorough assessment of their health. Like palliative care, MAID honours patients’ wishes and relieves suffering. We all will experience death, and some of us will experience an un-
pleasant death with varying severities of pain and symptoms. This can be managed well through palliative care, and in most situations this is adequate. But MAID is an option for people whose quality of life has been reduced by their terminal disease, people who want to end progressive pain, symptoms, and treatments coming their way before death. www.longtermcarenews.ca
MAID IS AN OPTION FOR PEOPLE WHOSE QUALITY OF LIFE HAS BEEN REDUCED BY THEIR TERMINAL DISEASE, PEOPLE WHO WANT TO END PROGRESSIVE PAIN, SYMPTOMS, AND TREATMENTS COMING THEIR WAY BEFORE DEATH. Dr. Mike Leckie and I are two physicians in North Bay who have been offering assisted-dying since the federal government passed Bill C-14 in June 2016. The legislation gives eligible patients the option to request medical assistance in ending their lives – and gives doctors and nurse practitioners the legal right to provide the service. Patients requesting MAID must be assessed by two independent physicians or nurse practitioners to determine their eligibility for the service. Physicians and nurse practitioners are the only medical professionals who can assess for eligibility, or prescribe or administer MAID. The first MAID case I performed was for a lady who was suffering and deteriorating. She could no longer do anything she valued and did not want more medications or palliative sedation. The day of her passing, she wore her best silk pajamas. Her hair was fixed and she had her makeup on. She got into her bed with her favourite song playing in the background. She said her final farewells, spoke softly about playing with her grandchildren by a brook in the woods, and she went to sleep. It was, by far, the most beautiful death I have witnessed in my 31year career. In the first year that the federal law was in effect, around 20 people in Northeastern Ontario chose a medically assisted death. “In May, my husband, who suffered from terminal cancer, asked for medically assisted death,” says Helen Eng. “He was a proud, competent man with an unwavering optimism about life. He wanted us to remember him like that. We did. In the final hours with him, we had sadness and tears –but joy, peace, and laughter too. He made sure of it. He was surrounded and supported by
the love of his family and friends. He was thankful. He had a serene smile when he said his final goodbye. It was a meaningful ending to a life well-lived.” MAID is one more possibility for patients who are dying and feeling they’ve lost control of their lives. Over 90 per cent of people with terminal and advancing illness who request MAID do so not for pain and symptom management, but for existential angst. Patients get an emotional release and reassurance when they know that this is an option for them. I’ve seen patients cry with relief. Whether they proceed or not, a weight is instantly lifted off their shoulders. Currently, in the region, there are ten doctors and nurse practitioners registered to provide MAID – and a number of clinicians who choose not to. There remains concerns about the number of providers being able to meet the demand. My priority for the NE LHIN is to build up the capacity to offer the service as quickly as possible, by training more clinicians to provide MAID. I’ve been working with the province for changes that will make MAID sustainable over the long-term. As a result, the NE LHIN will be the first site to provide provincially funded MAID training to interested physicians and nurse practitioners this fall. The training will take place in Sudbury September 29. I would ask clinicians contemplating offering this service, to witness a MAID passing and see for themselves what a meaningful experience it is. I believe this is one of the most important services that can be offered to a suffering, dying patient and their family.” LC
Dr. Paul Preston is VP Clinical, Primary Care Lead, NE LHIN. www.longtermcarenews.ca
Facts • May 31, 2017, the province established a Care Coordination Service to assist patients and caregivers in accessing additional information and services for MAID and other lifeending options. If people want to be connected with a physician or nurse practitioner who can provide Medical Assistance in Dying – call 1-866-286-4023 or TTY: 844-953-3350. • In Ontario, more than 500 people have chosen a medically assisted death since the law took effect in June 2016. • To be eligible for assisted dying a patient must be at least 18-years-old, be capable of making healthcare decisions, have a serious and incurable medical condition, be making a voluntary request for the procedure, and give informed consent. • Once MAID eligibility is medically confirmed and documentation is completed, a 10-day period of reflection is mandated by law. • MAID cannot affect life insurance - and MAID is no longer a mandatory coroner’s case, it is a coroner’s notification. • For more info visit https://www.ontario.ca/page/medicalassistance-dying-and-end-life-decisions#section-0
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Virtual reality & dementia care By Ilan Mester
magine walking into a long-term care facility where residents living with dementia have access to headsets that immerse them into a peaceful forest. This reality might not be that far off. Some hospitals are already integrating virtual reality (VR) for various
purposes – be it to educate healthcare workers, provide entertainment or sooth patients dealing with anxiety. But when it comes to people living with dementia – a population that’s on the rise, numbering more than half a million people in Canada alone – we’re still at the tip of the iceberg for integrating VR into their care.
14 Home and LongTerm Care News OCTOBER 2017
Researchers such as Lora Appel, who has a PhD in health informatics and specializes in applying technologies into different aspects of healthcare, are busy studying the impact of virtual reality on patients with dementia. Working out of the University Health Network’s OpenLab, Appel’s project is evaluating whether simulated natural environ-
ments decrease stress, anxiety and the desire to wonder in this population. “Virtual reality is very hot, innovative and upcoming,” says Appel. “I mean, it’s been around for a long time, but in it’s most recent incarnation it’s both more affordable and reaching a place where it’s getting to be more user-friendly.” www.longtermcarenews.ca
NEWS Appel wanted to study a population that was often unable to reap the benefits of nature, be it for physical or cognitive reasons. It’s no secret that people living with dementia are sometimes confined to long-term care facilities or their homes partly because they’re no longer able to navigate their communities independently. “There’s been some applications of virtual reality in healthcare – mostly phobia treatment and post-traumatic stress disorder. But the idea of testing it with a very difficult population like those that are cognitively impaired – if we can do that and prove that they tolerate the headset, we can be more confident that we can use it with different patients.” So what has Appel found? She’s in the midst of publishing her feasibility study, aptly titled Prescribing Virtual Reality. One of her major concerns was whether people with dementia would tolerate the VR headsets. “We have definitely more detailed analyses that we’ll report on, but I’d say that’s a very overall positive finding. The hardware doesn’t seem to bother them.” She also revealed an unintended outcome. “That’s the fact that VR seems to elicit conversation around memory, which intuitively makes sense. You see something and you kind of relate it to your personal experience. But we thought you’re going to get benefits from being outside in nature. And then for this population that have issues with memory, the fact that it makes them talk about past memories – maybe we can use this as a trigger in the future to kind of elicit moments of lucidity where they can remember their past.” However, Appel is quick to suggest this topic requires more research. In fact, she says one of the reasons many long-term care facilities are likely not using VR is because there still isn’t a ton of evidence for its use with this population. “The study that I’m running now is a feasibility study and we hope that once this is complete, since we have had positive outcomes, to do a more rigorous randomized control trial. These are studies that would guarantee that people who are randomly assigned to getting virtual reality vs. another therapy – if there are actually benefits.” Appel, who received funding through the Centre for Aging + Brain www.longtermcarenews.ca
WHEN IT COMES TO PEOPLE LIVING WITH DEMENTIA – A POPULATION THAT’S ON THE RISE, NUMBERING MORE THAN HALF A MILLION PEOPLE IN CANADA ALONE – WE’RE STILL AT THE TIP OF THE ICEBERG FOR INTEGRATING VR INTO THEIR CARE. Health Innovation (CABHI), says organizations like CABHI are vital for moving these technologies forward. “Without this grant from CABHI, the feasibility study would not have taken off,” Appel admits. “They’ve been supportive and always asking how they can be of greater help.” Sandra McKay, VHA Home HealthCare’s manager of research and evaluation, echoed Appel’s thoughts. Her exploratory study, which also received CABHI funding, looks at VR’s effectiveness as a tool (see story on page 18) for caregivers to manage symptoms like aggression and agitation in the home. “Myself personally as an academically trained researcher, I had a lot of questions,” admits McKay. “I had many concerns. There wasn’t a lot of available evidence – particularly when you consider that we were asking families potentially to use rather sophisticated devices independently in the home.” The study, which came after a point-of-care staff suggested using VR to support families, involves providing caregivers with a VR headset and a catalogue of videos for two weeks. If they end up using the technology, family members are asked to document the nature of the situation and the outcome. It’s still in the recruitment stage. However, McKay says that out of all the studies she’s worked on in her decade-spanning career, this one is garnering the most interest. She adds that one of the biggest misconceptions is the notion that VR headsets are expensive. “What is expensive is the phone and the data plan that need to accompany the headset. So that’s the catch. People sometimes say, ‘Oh, it only costs $100 for the headset, terrific.’ But you must have a Samsung Galaxy phone that to purchase is approximately $700, and then the data plan. So that’s where it becomes cost prohibitive,” she says, adding that older models and second-hand phones can be used to reduce costs.
But what if you wanted to create original, tailored content? That’s certainly possible. Digital Generals’ Terry Myers helps a number of healthcare organizations create compelling VR experiences. One of his latest projects, in collaboration with Baycrest Hospital and CABHI, uses VR to educate and create empathy for caregivers of people with Alzheimer’s. “Are you able to feel empathy for what they’re doing? The results say yes; people can feel empathy. We had users crying in the headset. We had people who would come out and just
pour their hearts out to us about how it made them feel in a positive, but also very intense way,” says Myers, adding that no two projects are the same and can range from just $2,000 to five or six digits. He says the work being done in collaboration with CABHI is vital, adding that it’s helping to answer questions related to return on investment and whether the technology is an effective education and therapy tool for dementia. “There’s no other avenue for the funding to get this started,” says Myers. While we’re still in the early stages of VR use in relation to dementia, Myers is a strong advocate for the medium. “The technology is just incredibly powerful. It’s kind of beyond anything that we’ve been able to use to talk to people, share stories and create feelings. It’s a very exciting space to be in and I think healthcare is a natural fit for it.” LC
Ilan Mester is the Communications Content Specialist for the Centre for Aging + Brain Health Innovation (CABHI).
Helping people live with independence, dignity and in comfort since 1925. • Nursing • Physio and other therapies • Personal care and support • Homemaking
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• Palliative support needs • Dementia care • Respite • Wound care
OCTOBER 2017 Home and LongTerm Care News 15
Early onset dementia Putting I am 18 and my mom was diagnosed with dementia. I want to help her and my dad, but feel that I cannot cope with what is going on. Dad is working and a mess. ome people may be surprised to hear that at only 18, you are already dealing with dementia in a parent. Most people under 25 usually deal with a grandparent who has dementia, but the early onset dementias create a challenge for people like you. Researchers often refer to this as an “off-time event” – an experience that happens at a point when it is not generally expected. Anyone can become a caregiver for a variety of reasons, but most people don’t plan on being in that role in their teens or in young adulthood. Most family members who care for parents
are over 50. And the older adults who need this support are generally in their 80s. In your case, it must feel difficult not to fit in! This diagnosis is particularly devastating for a young adult or even younger child. There is not a lot of research on this group as the focus has been on the spouses/partners; but dementia does and can impact families with young children and young people. Clinicians have noted that the young caregiver’s mental and physical health deteriorate over time. This affects them in a variety of ways as they transition into adulthood. Many of these youth still live with the parent affected by dementia. Clearly, the diagnosis destabilizes the whole family, but many report that health professionals have not been focused on giving young caregivers appropriate support. Many are dealing with an unpredictable situation at home while coping with the numerous challenges of just “growing up.” When friends are worrying about parties, a young caregiver may be fearful of their home situation. This feeling of being “off sync” with peers is very difficult. The general lack of knowledge about dementia leads to discrimination amongst family and friends, who often disappear. It’s hard to complete one’s education under such pressure and some young people elect to stop, disrupt or stay near home at a cost to their own long-term plans and careers. Sydney Perelmutter, whose mom has dementia, explains: “For the past year and a half, I have had to cope with my mother’s worsening dementia with little help from the community or professionals. Being a 20-year-old in university in this predicament is extremely unique and what I would ben-
efit from the most is proper counselling, outreach and advice to help me through this difficult process.” Sympathy is not what young carers report that they want. Many say that they want help with tangible, supportive ideas and help coping with the feelings of hopelessness that are often associated with this tragic situation. Many young people conceal their emotions and don’t share them with friends or counsellors. This puts them at emotional risk and needs to be watched for. A young parent being placed in a long-term care home creates another trauma that is often not similar to a young caregiver. These facilities are not generally equipped with programs and supports for young dementia clients. Again, this is a heart-wrenching situation for a young caregiver, who is witnessing their young parent now living amongst people who could be more than 30 years older than them. The key is to find information and support. Your local Alzheimer’s society is a good place to start. There are now more supports being provided to young carers, but it is also important to ensure that a feeling of belonging and understanding is present. There are professionals in the system that specialize in grief and trauma counselling for older adults and their older children; but one must find new service models for families who are in an earlier life stage. A good friend or family support can do wonders for you; but as a community we need to help these young people do the difficult job that was thrust upon them. Your mom is lucky to have you there for her, but I encourage you to get help for your needs as well. Check out the documentary Much Too Young which was screened on TVO on Sept. 21, world Alzheimer’s day. LC
Nira Rittenberg is an occupational therapist who specializes in geriatrics and dementia care at Baycrest Health Sciences Centre and in private practice. She is co-author of Dementia A Caregiver’s Guide available at baycrest.org/dacg. Email questions to caregivingwithnira@ baycrest.org. This article originally appeared in the Toronto Star. 16 Home and LongTerm Care News OCTOBER 2017
patients first can save our health system
By Kapil Khimdas and Danyaal Raza t’s no secret: Ontario is getting older. The number of seniors in our province has been steadily increasing and over the next twenty years, will double. Including factors like increased use of health services and evolving technology, this will result in a substantial increase in demand across the health system. Those services will cost money. In just the continuing care sector (e.g., home care, rehab facilities, longterm care homes) public spending will need to increase by $16 billion. That doesn’t include an increase in private spending of another $10 billion. Our provincial government’s response to this challenge is the Patients First Act, signed into law, and currently being put into action. Patients First is a structural reorganization of agencies in the community health system, empowering local health authorities with more responsibility for primary and home healthcare delivery. How exactly will this help us take care of double the number of seniors by 2037? It’s not entirely clear – at least not yet. There is a risk that this reorganization with a friendly name will just shuffle activity from one branch of government to another. But there’s opportunity for a real transformation in the way we deliver services. Taking care of more seniors does not have to be more expensive. That’s the potential of Patients First: to re-organize our health system to treat patients before they become patients and to organize care around cost-effective, community-based care instead of relying on the traditional, expensive, hospital environment.
There are three major ways LHINs can use their new responsibilities to drive change. First, improve what they’re doing already. We know better community and primary care can avoid expensive hospital admissions. Yet our health system is still largely organized around hospitals, while the illnesses that affect most patients are chronic and can be better managed in the community. That’s where LHINs should start to shift the focus of care. For example, why not give hospitals the means and funding to organize their own home care and measure their performance on reducing admissions? The second is by prioritizing populations according to those who can benefit most. We know that our most socio-economically challenged communities have the highest rates of illness and the lowest levels of primary care support. LHINs should wrap fo-
cused support around these areas. For example, why not actively direct home care and primary care funding towards these communities? The third is to improve population health and disease prevention. Our rates of preventable illness are higher than they could be. What if we focused on reducing them? Population health is an approach to health system planning that focuses on services that allow us
to lead healthier lives, today, tomorrow and well into the future. LHINs can use their new responsibilities to cement a population health approach to all services in their communities. For example, LHINs could collaborate with primary care practices to measure and monitor overall health status and give family doctors the financial flexibility to prescribe any kind of support – like housing or income sup-
ports – that result in healthier patients and communities. In shifting the focus of our health system towards prevention and community care, we will need to be very mindful of Canada’s promise of universal care for all. The Canada Health Act (CHA) is what guarantees that all hospital-based services must be publicly funded and accessible to all. But in the community, the CHA only does so for physician services. This shift to preventative and community-based care needs to be undertaken with a promise of universal access if we wish to create a health system that will effectively serve a greying population. Patients First could be an incredible moment for health sector leaders to dramatically reshape how our healthcare is delivered in Ontario – to truly realize the provincial government’s vision to make Ontario the “healthiest place in North America to grow up, and to grow old.” LC
Kapil Khimdas has worked in senior management roles in health systems in Canada and the United Kingdom. He is a graduate of the Kennedy School of Government and Business School at Harvard University. Danyaal Raza is an expert advisor with EvidenceNetwork.ca, family physician at St. Michael’s Hospital and Assistant Professor with the Department of Community & Family Medicine at the University of Toronto.
Could virtual reality help calm patients with Alzheimer’s? By Pamela Stoikopoulos
“Mornings were my mom’s ‘witching hours,’” says Trish, a caregiver to her mother – who lived with Alzheimer’s disease – for nearly seven years before she passed away. “My dad was normally very easygoing and unflappable, but during those moments, he didn’t know what to do. My mom was fearful of something but she couldn’t communicate it. It was really stressful for everyone.”
18 Home and LongTerm Care News OCTOBER 2017
NEWS rish’s experience caring for someone with Alzheimer’s disease isn’t all that uncommon. In fact the Alzheimer’s Association reports nearly 60 per cent of Alzheimer’s and dementia caregivers experience emotional stress related to caregiving, and about 40 per cent suffer from depression. Burnout is also a very real issue. Virtual Calm – a new home care research study led by VHA Home HealthCare (VHA) – a not-for-profit Ontario-based agency – hopes to provide some “virtual” solace and support to these stressed out caregivers. The research study aims to uncover whether virtual reality (VR) videos can help quell rising distress or aggression in Alzheimer’s and dementia patients being cared for at home. Virtual Calm is funded by the Centre for Aging and Brain Health Innovation’s (C-ABHI) Spark program* and plans to begin working with caregivers and patients in the late fall. “Distress and aggressive behaviour of someone with dementia or Alzheimer’s can really be a challenge for
THE RESEARCH STUDY AIMS TO UNCOVER WHETHER VIRTUAL REALITY (VR) VIDEOS CAN HELP QUELL RISING DISTRESS OR AGGRESSION IN ALZHEIMER’S AND DEMENTIA PATIENTS BEING CARED FOR AT HOME. caregivers who are already emotionally and physically stretched,” notes Dr. Sandra McKay, VHA’s research manager and lead on the project. “Certain times of day or paticular activities can trigger aggressiveness or distress in some home care clients (patients) with Alzheimers and dementia. We’re hoping to ‘distract’ clients before this happens with a relaxing virtual walk on the beach or a stroll through a tranquil forest and give caregivers a valuable tool to ease challenging behaviours.” Other virtual reality video studies with patients who have dementia or Alzheimer’s have shown promising result in clinical settings. The Virtual Calm project will take this technology into the community – where many people with Alzheimer’s and dementia are cared for – to help clients with Alz-
heimer’s or dementia experience the calming effects of a peaceful “virtual journey” when they feel distress or agitation in the home. “Caregivers know best how to read the cues of their loved ones,” says Dr. McKay who notes that the research team will work closely with caregivers to first decide on what kinds of VR videos their loved one is most likely to respond to and also to ensure VR is used proactively (i.e. before they become aggressive or distressed) so the virtual journey is a positive experience for everyone involved. While in past, VR was considered a “high-tech” and “high priced” investment, these tools are becoming much more within reach to everyday Canadians. The cost of 3D viewers continues to drop and the availability of free
3D VR videos is growing. “What’s so exciting about this research – if our theory proves positive – is its potential to become part of mainstream home care. These tools are becoming more and more accessible which I think provides us with a real opportunity to help caregivers and their loved ones too,” notes McKay. Though it is too late to help Trish in her care for her mother, she is equally enthusiastic about the possibilities of this project. “I think this kind of research is so needed. Most caregivers who are dealing with Alzheimer’s want to keep their family members at home – but they need all the help they can get. I would have loved to have some tools that could have helped me calm my mom and take her fears away,” she says. *C-ABHI’s SPARK program is made possible through generous funding provided by the Government of Ontario through the Ministry of Research, Innovation and Science, and by the Government of Canada through the Public Health Agency of Canada, and by the Baycrest Foundation. LC
Pamela Stoikopoulos is the Senior Communications and Public Relations Manager at VHA Home HealthCare.
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The persistent problem of
pressure sores By Ellen Kirk-Macri and Susan C. Jenkins ressure sores – also called bed sores – can be difficult to prevent, even with good nursing care. However, good nursing care can help identify them early when they are easiest to treat. Knowing what causes them and who is most likely to develop these sores can help you identify what to do to reduce the chance they will occur. When there is too much pressure on one area of skin for too long, blood flow
can be reduced, causing skin cells to die and allowing a sore to form. While these sores are often associated with older people because their skin tends to be more fragile, they can affect anyone with limited mobility, even children. In addition to age, other factors that increase the risk of developing pressure sores include: • Poor circulation due to a condition such as diabetes or vascular disease, smoking, or wearing compression stockings
20 Home and LongTerm Care News OCTOBER 2017
• Poor nutrition – especially a diet lacking in protein, vitamin C, and zinc • Reduced ability to perceive pain from nerve damage, such as diabetic neuropathy • An altered mental state that limits a person’s ability to take preventive actions • Inability to control the bladder or bowels that causes areas of constantly moist skin, which
increases the risk of skin breakdown • A body mass index (BMI) that is either very low or very high – people with a very low BMI may not have enough padding around their bones, and people with a very high BMI can have too much added pressure on tender areas
WHAT TO WATCH FOR The warning signs of a pressure sore may include: www.longtermcarenews.ca
Treatment do’s and don’ts
INSPECT SKIN DAILY FOR SIGNS OF PROBLEMS. THE SORES DEVELOP IN STAGES, AND IDENTIFYING THEM IN THE EARLIER STAGES ALLOWS THEM TO BE TREATED QUICKLY AND REDUCES THE RISK OF COMPLICATIONS. • Unusual changes in skin colour or texture • Swelling • Tenderness or pain • Skin on one area that feels cooler or warmer to the touch than the surrounding skin • Pus-like seepage from the skin People who use a wheelchair often develop pressure sores over the tailbone, buttocks, spine, shoulder blades, and on the backs of the arms and legs where they rest against the chair. People who are confined to bed are likely to develop them on the back or sides of the head, the shoulder blades,
hip, lower back, tailbone, heels, ankles, and the skin behind the knees.
AN OUNCE OF PREVENTION Frequent repositioning can help avoid stress on the skin. If you have the ability to shift your weight, change your position about once every 15 minutes. If you are a caregiver for someone who uses a wheelchair, you may need to help the person move around. If you are a caregiver for someone confined to bed, you will need to make sure the person is repositioned at least once every two hours.
There are specially designed cushions and mattress pads available that relieve pressure and ensure that the body is well positioned. However, do not use a donut-shaped or ringshaped cushions, because they focus pressure on the surrounding tissue. Inspect skin daily for signs of problems. The sores develop in stages, and identifying them in the earlier stages allows them to be treated quickly and reduces the risk of complications. Family and friends of people in assisted living facilities can work with staff to ensure proper preventive care.LC
• Gently wash and dry the area • Ask a healthcare provider if you should apply a moisturizer, which one to use, and how to use it • Protect the sore with a special dressing • Avoid further injury by reducing pressure and friction on the area • If the sore changes or a new one forms, see a doctor
Don’t • Do not use hydrogen peroxide or iodine cleansers • Do not massage the skin near the sore • Do not use donut-shaped or ring-shaped cushions
Ellen Kirk-Macri is a registered nurse and certified diabetes educator. Susan C. Jenkins is a freelance writer and editor specializing in medicine, pharmacy, and healthcare. She can be reached at email@example.com.
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Updated best practices guide to cut antipsychotics use in residential care By Rumana D’Souza ver the last decade, the overuse of anti-psychotics in residential care has raised public concerns about the health and safety of residents and care providers alike. The BC Care Providers Association released the Best Practices Guide for Safely Reducing Anti-Psychotic Drug Use in Residential Care in 2013. The Association’s Policy & Research Department is working towards releasing the 2017 Best Practices Guide this fall to continue helping care providers lower the use of anti-psychotics among seniors under their care. The Canadian Mental Health Association defines anti-psychotics as drugs used “to treat the severe distortions in thought, perception, and emotion that characterize psychosis.”
Although originally developed to treat schizophrenia and bipolar disorder, they are being increasingly prescribed to treat behavioural and psychological symptoms associated with dementia. According to a 2016 report from the Canadian Institute for Health Information, nearly half of all older adults living in long-term care facilities in Canada are prescribed antipsychotic drugs. According to PharmaNet, 50 per cent of all seniors in residential care in B.C. were prescribed anti-psychotics between April 2010 to June 2011 – a figure that jumped from 47 per cent in 2006 to 2007, and 37 percent in 2001 to 2002. Over 450,000 anti-psychotic prescriptions were handed out in B.C. between April 2010 and June 2011 – at a cost of $9.2 million to PharmaCare.
Over-medication is an issue among all aging adults, not just those in residential care. The BCCPA released a Backgrounder on Reducing Polypharmacy in B.C.’s Continuing Care Sector in 2016 that highlights the larger issue of polypharmacy among seniors, and also addresses specific concerns about anti-psychotics, anti-depressants and off-label drug use. In 2012, B.C.’s Ministry of Health warned the public of the link between anti-psychotics and an increased risk of illness and mortality in dementia patients – for which reason the drugs should be used with caution. Not only does the overuse of anti-psychotics pose a risk to the health of residents, it can also compromise the safety of staff. Strategies outlined in the guide ensure residential care homes are a safe place to work for care providers.
Like the 2013 Best Practices Guide, the updated version will feature successful anti-psychotic drug reduction strategies implemented by several B.C. residential care providers who are members of the Association. Lara Croll, Policy Analyst at the BC Care Providers Association, said interest in the Best Practices Guide from members has been tremendous. “While there is still more progress to be made, our members are steadily working towards reducing and eliminating the use of anti-psychotics, and using non-pharmacological approaches to care for residents living with dementia and cognitive impairment,” Croll said. The 2017 Best Practices Guide will profile Menno Place, Creekside Landing (Kaigo), Park Place Seniors Living, Arrowsmith Lodge, and KinVillage among many others. LC
Rumana D’Souza is the Digital Media & Communications Coordinator, BC Care Providers Association. 22 Home and LongTerm Care News OCTOBER 2017
Public inquiry will lead to better care By Doris Grinspun t was a tragic day for the nursing profession when news broke last October that former RN Elizabeth Wettlaufer would be charged with the murders of eight elderly Ontarians using a lethal dose of insulin in each case. She was also charged with four counts of attempted murder and two counts of aggravated assault. As details emerged about this serial killer, RNAO and its members were outraged that a colleague could commit such a gross violation of the most sacred principle of our profession – the unwavering commitment to ensure the well-being of patients and their families. RNAO began advocating for a full public inquiry when the former RN pleaded guilty to the murders in early June. As the only nursing organization to issue this call, we spoke to the media, sent letters to political leaders, and circulated two action alerts urging members to voice their outrage. More than a thousand people joined us in demanding answers to what happened, how it happened, and what can be learned from an organizational, regulatory and system perspective to ensure nothing like this ever happens again. On June 26, the same day Elizabeth Wettlaufer was sentenced to life in prison with no chance of parole for 25 years, the government announced it would launch a public inquiry. The details of that inquiry were revealed on Aug. 1, and nurses across the province are applauding the government for having the courage to put this tragedy under the microscope. We are especially pleased that Premier Kathleen Wynne, Attorney General Yasir Naqvi and Health Minister Eric Hoskins have heeded our calls for an inquiry with a broad mandate. We are now urging Justice Eileen Gillese, a sitting judge with the Ontario Court
Some of the strategies to be outlined in the 2017 guide include: • Participating in formal polypharmacy reduction initiatives, including CLeAR (Call for Less Antipsychotics in Residential Care). • Providing all staff with education and training on person-centered care, violence prevention, and working with people with dementia. • Working with pharmacists and physicians to reduce or eliminate anti-psychotics prescriptions, where appropriate. • Engaging with families to educate them about the potential risks of antipsychotics. • Croll added the guide will be of use both to care providers looking to begin work on this issue, and those looking to enhance their existing initiatives.
FUNDING MODELS IN LONG-TERM CARE PENALIZE NURSING HOMES FOR IMPROVING PATIENT OUTCOMES. of Appeal since 2002, to make full use of this broad mandate as the inquiry’s commissioner. She must look at anything and everything that might have contributed to this horrific tragedy. RNAO is also urging Justice Gillese to look beyond this particular case and make recommendations to address the failings of our long-term care system, including examining legislation and regulations, funding models and staffing, and any other aspects required to create a safer environment for seniors living in nursing homes. RNAO has received numerous calls from nurses who have revealed to us that things are just not right in their nursing homes. They have told us patients are not turned as often as necessary, and some sleep all night in the same soiled diapers. We have thanked each caller for their courage to disclose the truth. And we are urging others to continue to share their concerns with us. We know the vast majority of nurses – RNs, RPNs and NPs – go to work wanting to do good and wanting to deliver safe, quality care. The staffing circumstances, however, are deficient, if not deplorable. Older persons deserve the best evidence-based care we can provide. Their vulnerability is greater than ever as they arrive in long-term care older and frailer, and with more cognitive deterioration. And yet, the funding and staffing models in the sector are archaic. By legislation, only one RN is required per nursing home in Ontario. Some nursing homes have as many as 300 residents. This is outrageous and unacceptable.
Funding models in long-term care penalize nursing homes for improving patient outcomes. RNAO has been going into long-term care homes across this province for many years with best practice guidelines (BPG) that teach regulated and unregulated staff about preventing pressure injuries, preventing falls, managing incontinence, reducing the use of restraints, and so much more. These homes are funded on the basis of complexity of care. This means that when our BPG recommendations are implemented and patient outcomes improve, care becomes less complex and funding is decreased. This too is outrageous and unacceptable. We need to bring funding and staffing models into the 21st century, and a public inquiry will help us do that. We also need to delve more deeply into when and how regulatory colleges tackle disciplinary issues. We now know that Wettlaufer was fired in 2014 for making a number of medication errors, but was not investigated by CNO at that time. A disciplinary hearing this July also revealed the former nurse was investigated for stealing medication in 1995. How was she able to continue to practise despite these red flags? We need to muster the courage to look in the mirror and learn. The tragic murders of eight Ontario seniors will forever remind us that health professionals are in a very privileged position. Nurses enjoy higher public trust than any other profession (see page 11). We must cherish that trust by leaving no stone unturned. This public inquiry is our collective opportunity to do just that. LC
Doris Grinspun, RN, MSN, PhD, LLD (hon), O.ONT, is chief executive officer for RNAO. Follow her on Twitter @DorisGrinspun This column was originally published in the July/August issue of Registered Nurse Journal. OCTOBER 2017 Home and LongTerm Care News 23
Why music works in dementia care By Bev Foster usic accompanies us on our journey and connects us to people, places and events in our lives. It is cross-coded into life passages and is a powerful stimulus for the brain, both emotionally and cognitively. When it comes to memory care – when semantics, comprehension, working memory and processing are getting muddled and lost – music reaches into places where neural activity may still be intact or least somewhat active. There are lots of reasons why music is a natural choice in supporting persons living with dementia (PWD). For example, lyric recall and musical melodies may be remembered when names, faces, and menus are forgotten. Neuroscience teaches us why. Music gets stored in both sides of the brain; music gets processed in the brain in many places. For example, melody gets processed in one place, words are stored in another, various parts of rhythm like tempo, duration, metre, in other places. This may be why in dementia, one is able to retain musical events because they are stored beyond an impacted area. New songs and musical skills, even language recovery may be learned because of neuroplasticity. Neurons find a way to connect around a blocked or damaged area in the brain making it possible to form new neural pathways. This may be possible for some PWD. Music triggers and helps PWD recollect events, people, and places which have emotional connections that have been important and meaningful. When memories are first stored, feelings are often attached with that memory. We know that memories are stronger when attached to emotions. Music acts as a form of non-verbal communication and a way to express in dementia care. Dr. Naomi Feil, founder of validation therapy demonstrates this well in her encounter with Gladys Wilson. Music powerfully reframes what would be considered a responsive behaviour. Gladys’ tapping action which moves in exact time
Music acts as a form of non-verbal communication and a way to express in dementia care. with the rhythm, becomes an opportunity for connection, intimacy and communication. Research shows that familiar music has the greatest impact on health and well-being. Not that other music can’t be used, but to optimize impact, preferred music works best. Personalized music may reduce agitated or combative behaviors. Individualized music helps to restructure identity and preserve the self in PWD. Carryover effect, that is impacting connections and appropriate behaviours because of musical engagement, may last from one hour up to six weeks. While carryover effect does not
occur every time, music has the capacity to reconnect neural pathways, and wake up that which may be broken, lost, or dormant. Doing music together contributes to quality of life. This may happen through music listening, music-making or engaging in musical conversations. In this way, key psychosocial needs in PWD, identified by Kitwood, like inclusion, attachment, occupation and comfort, may be met. Caregiver-implemented musical activities rather than therapist-led sessions may reduce frustration for a PWD. Participating with family members, especially singing, is a very acces-
sible way for meaningful interaction to occur. Singing can be performed by care staff when administering medication, bathing, portering, transferring etc. Music is an activity that can be used throughout the dementia trajectory. While in early stages, music may stimulate a recollection or memory, in mid-stage, singing helps in cognition. Singing is recommended as an integral part of any programming provided for persons in late stage dementia. At end of life, music provides beauty and aesthetic as well as comfort, and intimacy. Music may be used with other modalities such as dance, art, cooking, drama, crafts etc. It can provide a soothing or stimulating background when working in tandem. Music by itself or used in a co-modal way offers meaningful activity to PWD. LC
Bev Foster, MA, BEd, BMus, ARCT, AMus, is Executive Director of the Room 217 Foundation, a social enterprise dedicated to care through music. For more information on Room 217 resources and music care training, visit www.room217.ca. 24 Home and LongTerm Care News OCTOBER 2017
Why we need improved oral health in hospital, home care and long-term care services
By Mary McNally ome years ago, a retired university professor visited my dentistry practice. He was fit and had a pleasant smile. He hadn’t seen a dentist in over five years, partly because he had lost his private health benefits when he retired, so it wasn’t surprising that he needed dental care. He had most of his own teeth but required a couple of extractions for advanced gum disease along with some other minor routine care. His was not an unusual pattern for someone 76 years old, but there was no reason to predict that he would lose any more teeth if they were looked after. I didn’t see this patient again for three years. The change in his dental health was dramatic. Shortly after our first visit, the professor had a stroke. As a result, he spent 18 months in acute and rehabilitative care and had been living at home with home support care for over a year. When I saw him this time, we were able to save only four of his teeth with the remainder lost to rampant decay and gum disease. The professor’s downward spiral seems dramatic, yet stories like his are becoming increasingly common for older adults. Like many others of his generation, he was likely the beneficiary of the protective effects of fluoridated water and toothpaste throughout his life. He had a good education and a good job with dental benefits. He was a senior who should not have been destined for dentures. So what happened? “With age comes a mouthful of trouble” is a cautionary line that rings all too true. When my patient retired and lost dental benefits, regular visits to the dentist ceased – possibly when he needed them most. Following his stroke, he was required to rely on in-patient acute care, rehabilitative
care and then continuing care to support his routine personal mouth care needs. In Canada, these care systems are known to have inadequate infrastructures and standards of care in place to support oral health. Advocating for a dependent loved-one, retired Nova Scotia nurse Lillian Sutherland
recently challenged others to “have a look in your loved one’s mouth to see his/her state of care. Can you imagine not having your teeth cleaned for months, or never?” That’s the reality for too many Canadian seniors. The mouth is the entry point to a healthy body – to eat, drink and breathe – and to life’s pleasures of
socializing and communicating with others. Yet as a focus of general and personal health, the mouth remains separate from the body in our publicly funded healthcare system. This is a double-edged problem for the increasing numbers of Canadians who are frail and dependent. Although it tends to get the greatest attention, the problem doesn’t arise only from difficulty accessing professionally delivered oral health services external to the public health system. Often an oral health crisis comes about simply because the necessary day-to-day oral healthcare required from within publicly supported institutions and programs fails our seniors. On the surface, brushing and flossing may seem to be mundane tasks. But when providing this care for others, it requires skill, the right resources and the commitment and will to ensure it is done well and regularly. Efforts are being made to respond to these needs. For example, the Registered Nurses Association of Ontario has developed the Oral Health Nursing Best Practice Guidelines which aims to address the daily oral care needs of dependent adults and are applicable to multiple care settings including acute, residential and community practice settings. In Nova Scotia, Brushing up on Mouth Care translates oral care best practices into user-friendly and accessible toolkits and resources to enhance care, also across multiple care settings. Yet, until meaningful policy is introduced by relevant provincial health ministries to ensure that best practices for oral care assessment and care-planning are being met within each of these settings, gaps in this essential element of personal care will persist. Care providers in medicine, nursing, dentistry, rehabilitation and continuing care represent those whose voices for advocacy could go a long way toward improved quality of life for their patients, clients and loved ones. LC
Mary McNally is an expert advisor with EvidenceNetwork.ca, a Professor in the Faculties of Dentistry and Medicine (Bioethics) at Dalhousie University in Halifax, Nova Scotia and a member of Canadian Frailty Network. Her clinical and research interests largely focus on developing pragmatic solutions and policy recommendations to address inequity and access to oral health care for vulnerable populations. 26 Home and LongTerm Care News OCTOBER 2017
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1 Brennan, M.R.; Milne, C.T.; Agrell-Kann, M.; Ekholm, B.P. Clinical 5F1<E1D9?>?6121BB95Bɥ<=6?BD85=1>175=5>D?69>3?>D9>5>35
associated dermatitis (IAD) in an open label, non-randomized, prospective study. Accepted for publication in Journal of Wound, Ostomy, and Continence Nursing (JWOCN), (n=9). 2 3M clinical reference study number EM-05-013236. 3 3M clinical reference study number EM-05-013262.
Skin and wound detective By Diane Wild hen Lisa Hegler started her position as a skin and wound clinician at Burnaby Hospital in 2009, she discovered a culture where “red bottoms were the norm” and at least eight referrals a day came in for patients suffering from skin breakdowns in their genital areas. With a little detective work, she realized that with little to no bladder and bowel function assessment, all patients were being put in briefs with soaker pads on their beds, exposing their skin to urine and feces for prolonged periods and causing those hard-to-heal wounds. She also discovered that there was a connection to the habit of putting most patients in briefs with the incidence of hospital-acquired urinary tract infection rates, and suspected that many reported pressure injuries were actually caused by these skin breakdowns. Another issue was the danger of sending patients home worse off in terms of continence than when they arrived. “I was hearing staff telling patients ‘go in your diaper and when I have time I’ll come and change you,’” Lisa says. “We know that elderly people in particular can lose that brain to bladder and bowel connection and become functionally incontinent, and that’s the leading cause of admission to residential care – families can’t cope with the cost and time of urine and fecal incontinence.” Lisa and her colleagues, including Misty Stephens, Marcia Carr and Maneet Samra, were out to change the culture, which was only possible with strong leadership support and continence education built into venues such as huddles, lunch and learns, grand rounds, and regional training. After the rollout of 48/6 came a renewed focus on assessing and main-
Lisa Hegler is a skin and wound clinician at Burnaby Hospital. taining a patient’s usual bowel and bladder function, but part of the issue was that briefs were the one thing available to staff for toileting, other than physically getting patients to the bathroom. Lisa and her colleagues reviewed the available supplies to ensure staff had access to external urinary pouches, urinary condom catheters, fecal collection devices, and urinals for women. Then surgical wards went briefless and saw no urinary tract in-
fections for the first few months. The rest of the hospital, with the exception of Emergency, followed suit the following year. The result? Burnaby Hospital went from those eight referrals a day for continence-related dermatitis to six cases in three months. They saw a 60 per cent reduction in hospital-acquired urinary tract infection rates and their pressure injury rates went from 12 per cent in 2013 to four per cent in 2015.
Now the adult continence protocol developed at Burnaby has rolled out to other Fraser Health hospitals, been presented at conferences in Montreal and Salt Lake City and an article about the implementation of an acute adult continence protocol is to be published. It’s no coincidence that one of Lisa’s favourite quotes is “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” LC
Diane Wild works in communications at Fraser Health. www.longtermcarenews.ca
OCTOBER 2017 Home and LongTerm Care News 29
Aching legs and chronic foot issues do not have to be an occupational hazard.
aching feet By Barbara Grant inally home after a busy day – or night – at work and the first thing you do is take your shoes off and put your feet up. They are hot, itchy, swollen and sore. “Par for the course,” you figure. “I’m on my feet all day. Some days I barely sit down at all! Of course my feet hurt. So do my legs. It’s practically part of the job.” Aching feet and legs can be a result of being on your feet day after day. The wear and tear from working long, exhausting shifts can contribute not just to aches and pains but also to persistent cramps, corns and callouses. It can also lead to more serious problems including bunions, fallen arches, plantar fasciitis, and knee, hip and back pain. But aching legs and chronic foot issues do not have to be an occupational hazard. There is much we can do to prevent and treat feet and leg pain before it becomes a chronic dilemma and a literal pain in the butt.
WEAR GOOD SHOES, BUT BE SURE TO RUN BAREFOOT It almost goes without saying that good quality footwear is important if you are on your feet all day. Shoes offer cushioning and support, not to mention provide anti-slip protection and assist in fall prevention. But it is important to avoid keeping your feet encased in shoes all day, every day. Spend some time around your home each day barefoot or in soft slippers.
This gives your toes and feet a chance to spread out and for the skin to cool and air out. Walking barefoot also stimulates the nerve endings at the bottom of your feet. These nerves send information to the brain that instructs your body to maintain balance and equilibrium.
INCREASE AGILITY IN YOUR FEET, TOES AND ANKLES There are 33 joints in the foot! Those joints need to move to enable you to walk and balance. If they stiffen up, the forces from the ground that hit the foot with each step transfer up to the shin and ankle contributing to aches and pains. Maintaining and increasing mobility and range of motion in the toes, feet and ankles stimulates blood flow and contributes to reduced swelling. Moving the joints of the feet and ankles and stretching the calf muscles hydrates the connective tissue and can help decrease the strain that contributes to calf pain and plantar fasciitis. More agile feet and ankles also create better balance and proprioception, and decrease the risk of falls.
STRENGTHEN YOUR FEET AND ANKLE MUSCLES There are over 100 muscles, tendons and ligaments in each foot. All the muscles of the lower legs, save one, connect to the feet. The strongest tendon in the body, the Achilles tendon attaches the big calf muscles to the heel. As well there are numerous intrinsic muscles of the feet that maintain the arches and move the toes. Your feet form the foundation of your standing body. Just like you can’t build a solid house on a crumbling foundation, you can’t build a strong body on weak feet. Strong, supple feet and ankles give you a better and more effective base of support to transfer force from the ground up through your legs, lower back and upper body.
MAINTAIN A HEALTHY WEIGHT
intake and getting regular exercise. Walking, preferably outside and with a friend can be great exercise for weight maintenance and to help combat stress.
PAMPER YOURSELF Pedicures, foot rubs, massages and soaks all contribute to nerve stimulation and better circulation. Its important to undergo regular foot care to make sure callouses, corns and toenails are kept in check and to avoid the risk of painful skin conditions and infections. No time to get to the nail salon or massage therapist? Roll a tennis ball under your foot for a minute or two then slather your foot in nice smelling lotion. Paying that extra bit of attention and care to your feet reap many benefits including a more comfortable work day and a better night sleep. Your feet and your whole body will thank you for it. LC
Extra weight puts excess stress on the feet, ankles and knees. Those extra pounds creep on so easily and are so hard to lose! Concentrate on eating a healthy diet, watching your portion
Barbara Grant is the President and founder of Retrofit Pilates, a full-service health and fitness studio in Toronto. For more information, go to www.retrofit.ca and visit Retrofit on Youtube at www.Youtube.com/retrofitpilates 30 Home and LongTerm Care News OCTOBER 2017
Ambiguous loss and grief Strategies for living positively with ambiguous loss and grief There are many steps you can take to live positively with your losses and grief while caring for someone with dementia: • Reflect on the losses that occur in the life of the person with dementia and your own life too. Acknowledge, express and share the grief you feel in response to those losses with a person or people whom you know will understand and be supportive. • Normalize and begin to accept your feelings of ambiguous loss and grief by talking to other caregivers who feel the same emotions and go through a similar experience, as well as Alzheimer Society staff who support people with dementia and their caregivers. • Stay connected to family and friends. Strengthen existing relationships, and be open to building new relationships with others who can be supportive and enhance your life amid the loss and grief. • Look after your own needs. Stay physically active, eat as well as possible, and do what you need to relieve stress. Take breaks from care. These things will boost your health and morale, and help you to make better decisions and be more effective as a caregiver. • Let your family and friends know how they can help, rather than assuming people know what you need. • Seek out information about dementia and what to expect. Talk to others who are caregivers at different stages of the journey. This knowledge gives you more ideas and information about how best to cope with the disease and plan for the future. • Seek out support from family and friends, professional organizations such as the Alzheimer Society, a professional counsellor, and/or participate in support groups. • Share your own experience and contribute by helping others in a similar situation. • Get involved and volunteer with your local Alzheimer Society. Learn how to advocate for your own needs and the needs of your family member or friend with the disease. • Express grief in creative ways through writing, painting, photography or other visual art forms. • Recognize and value your growth as a person, which resulted from caring for a family member with dementia. You may have learned new skills, such as handling finances, become more compassionate, or developed an inner strength and resilience you didn’t realize you had.
20 Eglinton Avenue West, 16th Floor, Toronto, Ontario, M4R 1K8 | 1-800-616-8816 | alzheimer.ca | firstname.lastname@example.org
OCTOBER 2017 Home and LongTerm Care News 31
If you remember when
rock was young, there’s a ﬂu vaccine specially designed for you.
As you get older, your immune response to inﬂuenza vaccines decreases. FLUZONE® High-Dose improves your immune response to inﬂuenza (also known as the ﬂu) and has demonstrated better protection of adults over 65 against the ﬂu than our standard dose ﬂu vaccine. In fact, FLUZONE® High-Dose vaccine is signiﬁcantly more effective than our standard dose vaccine in preventing the ﬂu – 24.2% more effective.
For more information, visit www.fluhd.ca FLUZONE® High-Dose is a vaccine used to prevent influenza in adults 65 years of age and older. Influenza (or flu) is an infection caused by the influenza virus. Annual vaccination using the current vaccine is recommended for prevention against influenza as immunity declines in the year following vaccination. Persons with a history of severe allergic reaction to eggs or egg products or any component of FLUZONE® High-Dose should not receive the vaccine. FLUZONE® High-Dose will only protect against the strains of influenza virus contained in the vaccine or those that are closely related. FLUZONE® HighDose will not protect against any other strains of influenza virus. FLUZONE® High-Dose is not indicated for the prevention of hospitalization or death after the onset of disease. As with all vaccines, FLUZONE® High-Dose does not protect 100% of people immunized. Allergic reactions can occur. The most common side effects are pain at the injection site and muscle ache. Contact your healthcare provider to see if this vaccine is right for you. For more information, visit www.sanofipasteur.ca. FLUZONE® is a trademark of Sanofi Pasteur. Sanofi Pasteur 1755 Steeles Avenue West, Toronto, Ontario M2R 3T4 © 2016 Sanofi Pasteur Limited. All rights reserved. DIN : 02445646 372-012c E 09/16
Published by Hospital News